GORD

Question 1

GORD is a very common condition, which is characterised by symptoms of … and …

Answer 1

GORD is a very common condition, which is characterised by symptoms of heartburn and regurgitation.

Question 2

Gastro-oesophageal reflux disease (GORD), is an extremely … condition. It is defined as reflux of stomach contents into the oesophagus, which is associated with troublesome symptoms and/or complications.

Answer 2

Gastro-oesophageal reflux disease (GORD), is an extremely common condition. It is defined as reflux of stomach contents into the oesophagus, which is associated with troublesome symptoms and/or complications.

Question 3

What is the estimated prevalence of GORD in Western Europe and North America?

Answer 3

In Western European and North American populations, the estimated prevalence is as high as 10-20%.

Question 4

High … and … are linked to development of GORD.

Answer 4

High BMI and smoking are linked to development of GORD.

Question 5

In some individuals, reflux of stomach contents causes troublesome heartburn symptoms and can cause damage to the oesophageal lining. Over time, this may lead to complications including …, strictures and … oesophagus. Factors implicated in GORD include:

Frequency of … episodes
… of the stomach content
… of acid from the oesophagus.

Answer 5

In some individuals, reflux of stomach contents causes troublesome heartburn symptoms and can cause damage to the oesophageal lining. Over time, this may lead to complications including erosions, strictures and Barrett’s oesophagus. Factors implicated in GORD include:

Question 6

Common risk factors for GORD

Answer 6

High BMI
Smoking
Genetic association
Pregnancy
Hiatus hernia: part of the upper stomach pushes up through the diaphragm
NSAIDs, caffeine & alcohol: conflicting reports

Question 7

What is the cardinal symptom of GORD?

Answer 7

The cardinal symptom of GORD is heartburn, which describes a burning sensation in the centre of the chest.

Question 8

… classically occurs after meals and is made worse by lying down or bending forward.

Answer 8

Heartburn classically occurs after meals and is made worse by lying down or bending forward.

Question 9

Other common features of GORD:

Answer 9

Regurgitation
Dyspepsia
Chest pain
Dysphagia (difficulty swallowing)
Odynophagia (painful swallowing)
Cough
Hoarse voice
Nausea and/or vomiting

Question 10

What is odynophagia?

Answer 10

Painful swallowing

Question 11

Collectively, the clinical manifestations of GORD can be divided into …. and …-… syndromes.

Answer 11

Collectively, the clinical manifestations of GORD can be divided into oesophageal and extra-oesophageal syndromes.

Question 12

Oesophageal clinical manifestations of GORD: (6)

Answer 12

Typical reflux syndrome
Reflux chest-pain syndrome
Reflux oesophagitis (inflammation and damage of oesophageal mucosa)
Reflux stricture (narrowing of oesophagus)
Barrett’s oesophagus (premalignant condition in the oesophagus)
Oesophageal adenocarcinoma

Question 13

Extra-oesophageal clinical manifestations of GORD:

Answer 13

Reflux cough syndrome
Reflux laryngitis syndrome
Reflux asthma syndrome
Reflux dental erosion syndrome
Proposed associations: idiopathic pulmonary fibrosis, sinusitis, etc

Question 14

GORD is a … diagnosis based on characteristic symptoms.

Answer 14

GORD is a clinical diagnosis based on characteristic symptoms.

Question 15

GORD is extremely common and can be diagnosed based on characteristic symptoms. There are several red flags, which should make you concerned about an alternative diagnosis and need for upper gastrointestinal (GI) endoscopy (i.e. gastroscopy) - what are these red flags? (5)

Answer 15

Weight loss
Anaemia
Dysphagia
New onset dyspepsia (>55 years)
Symptoms refractory to treatment

Question 16

It may be difficult to distinguish reflux-associated chest pain from ….

Answer 16

It may be difficult to distinguish reflux-associated chest pain from cardiac chest pain.

Question 17

Differential diagnosis of heartburn: (7)

Answer 17

Functional heartburn
Achalasia (failed relaxation of LOS)
Eosinophilic oesophagitis
Pericarditis
Ischaemic heart disease
Peptic ulcer disease
Malignancy

Question 18

The two key investigations in GORD are …

Answer 18

The two key investigations in GORD are gastroscopy and pH monitoring.

Question 19

…. monitoring - may be utilised where the diagnosis is uncertain or surgery is being considered in GORD - combined with gastroscopy

Answer 19

PH monitoring - may be utilised where the diagnosis is uncertain or surgery is being considered in GORD - combined with gastroscopy

Question 20

There are two techniques for assessing pH: what are they?

Answer 20

24-hour pH monitoring: small tube inserted through the nose and positioned in lower oesophagus. Can be combined with high resolution manometry (assesses motor abnormalities of the oesophagus).
Wireless pH capsules testing: insertion of pH capsule at gastro-oesophageal junction during gastroscopy. Carry recording device to capture episodes. Will naturally fall off wall of oesophagus and pass through GI tract.

Question 21

…-… … monitoring: small tube inserted through the nose and positioned in lower oesophagus. Can be combined with high resolution manometry (assesses motor abnormalities of the oesophagus).

Answer 21

24-hour pH monitoring: small tube inserted through the nose and positioned in lower oesophagus. Can be combined with high resolution manometry (assesses motor abnormalities of the oesophagus).

Question 22

…. pH …. testing: insertion of pH capsule at gastro-oesophageal junction during gastroscopy. Carry recording device to capture episodes. Will naturally fall off wall of oesophagus and pass through GI tract.

Answer 22

Wireless pH capsules testing: insertion of pH capsule at gastro-oesophageal junction during gastroscopy. Carry recording device to capture episodes. Will naturally fall off wall of oesophagus and pass through GI tract.

Question 23

When is gastroscopy indicated in GORD?

Answer 23

Gastroscopy is usually reserved for patients with red flags symptoms, suspected complications, symptoms refratory to treatment or those being considered for surgery.

Question 24

Gastroscopy is able to diagnose the presence of oesophagitis, Barrett’s oesophagus or an alternative diagnosis (i.e. oesophageal/gastric malignancy). Up to …% of patients with GORD will have a normal gastroscopy.

Answer 24

Gastroscopy is able to diagnose the presence of oesophagitis, Barrett’s oesophagus or an alternative diagnosis (i.e. oesophageal/gastric malignancy). Up to 50% of patients with GORD will have a normal gastroscopy.

Question 25

Los Angeles classification

The severity of oesophagitis can be graded into … - … using the Los Angeles classification:

Answer 25

Grade A: ≥1 mucosal break, each ≤ 5mm
Grade B: ≥1 mucosal break > 5mm. Not continuous between top of mucosal folds.
Grade C: ≥1 mucosal break, continuous between top of mucosal folds, not circumferential
Grade D: mucosal breaks involving more than three quarters of luminal circumference.

Question 26

Reflux can be divided into four different phenotypes based on endoscopy findings and pH monitoring - what are they?

Answer 26

Four reflux phenotypes:

Erosive oesophagitis: erosions seen at gastroscopy
Non-erosive oesophageal reflux: normal gastroscopy, but pathological acid exposure on pH testing
Acid hypersensitive oesophagus: normal gastroscopy, non-pathological acid exposure on pH testing but temporal association of reflux events with symptoms
Functional heartburn: normal gastroscopy, non-pathological acid exposure on pH testing and no temporal association of reflux events with symptoms.

Question 27

… …: erosions seen at gastroscopy

Answer 27

Erosive oesophagitis: erosions seen at gastroscopy

Question 28

Non-… oesophageal reflux: normal gastroscopy, but pathological acid exposure on … testing

Answer 28

Non-erosive oesophageal reflux: normal gastroscopy, but pathological acid exposure on pH testing

Question 29

Acid … oesophagus: … gastroscopy, non-pathological acid exposure on pH testing but temporal association of reflux events with symptoms

Answer 29

Acid hypersensitive oesophagus: normal gastroscopy, non-pathological acid exposure on pH testing but temporal association of reflux events with symptoms

Question 30

…. heartburn: normal gastroscopy, non-pathological acid exposure on pH testing and no temporal association of reflux events with symptoms.

Answer 30

Functional heartburn: normal gastroscopy, non-pathological acid exposure on pH testing and no temporal association of reflux events with symptoms.

Question 31

What is the main treatment in GORD?

Answer 31

The use of proton pump inhibitors (PPIs) is the cornerstone of treatment in GORD.

Question 32

Conservative GORD management -

Answer 32

There is variable evidence for lifestyle modifications in GORD. These include weight loss, smoking cessation and dietary modifications. Patients should be advised to avoid eating within two hours of sleep and elevation of the head of the bed may be helpful.

Question 33

Medical GORD management:

Answer 33

PPIs form the cornerstone of GORD treatment. PPIs prevent acid production within the stomach through inhibition of H+/K+ ATPases in parietal cells.

Patients with typical reflux symptoms can be offered a two-week PPI trial. Response is variable (40-90%). Alternative options include ranitidine, which is a histamine receptor antagonist, and over the counter antacids that can be used in combination with medications to neutralise stomach acid.

Patients with evidence of erosions should be offered PPIs to promote healing as they have the best efficacy.

Question 34

Patients with evidence of erosions should be offered … to promote healing as they have the best efficacy.

Answer 34

Patients with evidence of erosions should be offered PPIs to promote healing as they have the best efficacy.

Question 35

Patients with typical reflux symptoms can be offered a …-…. PPI trial. Response is variable (40-90%). Alternative options include ranitidine, which is a … receptor antagonist, and over the counter antacids that can be used in combination with medications to neutralise stomach acid.

Answer 35

Patients with typical reflux symptoms can be offered a two-week PPI trial. Response is variable (40-90%). Alternative options include ranitidine, which is a histamine receptor antagonist, and over the counter antacids that can be used in combination with medications to neutralise stomach acid.

Question 36

How do PPIs prevent acid production within the stomach?

Answer 36

PPIs prevent acid production within the stomach through inhibition of H+/K+ ATPases in parietal cells.

Question 37

What is the main surgical option for GORD?

Answer 37

The role of surgery has increased over the last decade. The main option being a Nissen fundoplication. This procedure involves wrapping the fundus of the stomach around the lower oesophagus. A good response to PPI therapy is associated with a good response to surgery, so patient selection is paramount.

Question 38

What happens in a Nissen fundoplication?

Answer 38

This procedure involves wrapping the fundus of the stomach around the lower oesophagus. A good response to PPI therapy is associated with a good response to surgery, so patient selection is paramount.

Question 39

When is surgery used in GORD?

Answer 39

Surgery is generally reserved for patients with clear evidence of reflux or associated complications who do not want to take medications or develop side-effects preventing long-term use.

Question 40

The major complications associated with gastro-oesophageal reflux include (3)

Answer 40

The major complications associated with gastro-oesophageal reflux include erosions, stricture and Barrett’s oesophagus.

Question 41

Reflux can lead to recurrent inflammation and damage of the … …. This predisposes to erosions, … formation due to chronic scarring and … transformation.

Answer 41

Reflux can lead to recurrent inflammation and damage of the oesophageal mucosa. This predisposes to erosions, stricture formation due to chronic scarring and malignant transformation.

Question 42

What is Barrett’s oesophagus?

Answer 42

Barrett’s oesophagus: a premalignant condition due to columnar metaplasia (transformation of one cell type to another) of the normal squamous oesophageal mucosa. Predisposes to the development of oesophageal adenocarcinoma.

Question 43

What are strictures?

Answer 43

Stricture: scarring and narrowing of the oesophagus due to repeated damage. Can cause dysphagia. May require dilatation or stenting.

Question 44

What is erosive oesophagitis?

Answer 44

Erosive oesophagitis: Inflammation of the oesophagus, which can lead to ulcers, bleeding and peptic stricture formation.